Denied Claims Blog

Crucial Deadlines for Unfair Claim Denial Appeals

April 2, 2012

Claims against the insurance you carry through the workplace can have an enormous impact on your life. So much so, that even the U.S. Department of Labor has taken the time to offer guidance to workers on how to file long-term disability claims and how to handle long-term disability claim denials. These guidelines help workers manage the claims process and offer advice on when to get help from a lawyer. 

ERISA Time Limits

An important part of understanding long-term disability claims is the Employee Retirement Income Security Act of 1974 (ERISA). This law is designed to protect the rights of employees who purchased disability coverage through their jobs. The law determines time limits for insurance companies to rule on claim denials, and the time limits for employees to appeal decisions. Among other things, the law and rules issued by the Department of Labor include requirements for the processing of benefit claims, the timeline for a decision when you file a claim and your rights when a claim is denied. Not all long-term disability plans are covered by ERISA protections, but they apply to almost all private-sector disability policies.

The Department of Labor points out that the only way to know your rights is to know what your plan covers. You can find this information in the summary plan description (SPD). This section of your policy details how the plan works, what benefits you should expect and how you can file a claim for those benefits. Unless the plan falls under a collective bargaining agreement, the following time limits are mandated by ERISA:

Time Limits

ERISA time limits follow calendar days, so they include weekends and holidays:

• Time to render a coverage decision – 45 days
• Time to notify more time is needed (must be circumstances outside the plan’s control) – 30 days
• Time for you to supply additional information – 45 days
• Time to decide a claim after you provide added information – 30 days
• Time for an extension on rendering a decision – 30 days
• Time for additional extensions – 30 days (only when authorized by you)
• Time to appeal a denial – 180 days (or longer depending on the plan’s SPD)
• Time to review an appeal – 45 days
• Time for an appeal extension – 45 days

The plan must notify you about its denial or need for additional information within the time provided. Requests for more time or information must include the reason for the need, an explanation of issues that remain unresolved, and a timeline of when you can expect a decision. A denial notification must give the reason for the denial, point to the part of the policy that applies and include details on the appeals process.

Once a decision to pay is made, there is no set time limit for payment. Plans are only required to pay benefits within a “reasonable time frame.” You have a right to copies of all claims documents, records and information free of charge.

Seek Legal Advice

The Department of Labor recommends that you consider seeking legal help if your appeal is denied. Our experienced attorneys will help you fight an unfair claims denial. If your claim was unfairly denied, contact our office as soon as possible for a free consultation and evaluation of your case.